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OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for inpatient treatment for mental illness under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s sixteen-year-old dependent son was hospitalized in a psychiatric hospital from November 4, 1987 through January 15, 1988 (72 days). The Employer provided coverage for the first 30 days of the hospitalization (from November 4, 1987 to December 4, 1987) and for an additional 30 day period (December 4, 1987 to January 3, 1988). It denied benefits for the remaining 12 days of the hospitalization because, under the terms of the Employer Benefit Plan, coverage is limited to a maximum of 60 consecutive days of hospitalization for mental illness.
Dispute
Is the Employer required to provide health benefits for the remainder of the Employee’s son’s psychiatric hospitalization?
Positions of the Parties
Position of the Employee: The Employer is required to provide health benefits for more than 60 consecutive days of the Employee’s son’s psychiatric hospitalization because continued hospitalization ,as medically necessary.
Employee
Employer
84-701 – May 23, 1989
Opinion of Trustees Resolution of Dispute Case No. 84-701 Page 2
Position of the Employer: The Employer has provided benefits for the maximum period specified in the Plan for a single psychiatric hospitalization. It is not responsible for providing any additional benefits for the Employee’s son’s hospitalization.
Pertinent Provisions Article III. A. (1)(e) of the Employer Benefit Plan states:
(1) Inpatient Hospital Benefits (e) Mental Illness
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. When medically necessary, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness. (More than 90 days of confinement for mental illness over a two-year period, (dating from the first day of hospital confinement, even if the first day of confinement occurred during a prior wage Agreement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the plan will not provide inpatient hospital benefits).
Discussion
Under Article III. A. (1)(e) of the Employer Benefit Plan, benefits are provided for hospitalization for treatment of a mental illness up to a maximum of 30 days per confinement. When medically necessary, benefits may be provided for extended hospitalization up to a maximum of 30 additional days per episode of acute mental illness. Accordingly, the Plan provides benefits for a maximum of 60 days of hospitalization per episode of acute mental illness. In addition, there is an overall limit of 90 days of hospitalization over a two-year period.
In this case, the Employee’s son was hospitalized for 72 consecutive days for treatment of mental illness. Hospitalization for 30 days beyond the initial, 30-day period was determined to be medically necessary and benefits were provided by the Employer for the first 60 days of the hospital stay. The Admission Report and treatment records indicate that the Employee’s son’s hospitalization was related to a single episode of mental illness. Because the plan states that benefits are limited to a maximum of 60 days per episode of acute mental illness, the Employer is not required to pay for more than the first 60 days of the Employee’s son’s hospitalization.
Opinion of the Trustees
The Employer has provided benefits for the Employee’s son’s psychiatric hospitalization for the maximum 60-day period set forth in Article III.A (1) (e) of the Employer Benefit Plan.